A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Monitor temporal artery temperature.
Restrain the infant's wrists.
Place the infant in a prone position.
Gently clean the suture line with povidone-iodine solution.
The Correct Answer is A
A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.": Incorrect because the child should exhale forcefully and quickly into the device, not inhale or hold their breath.
B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor.": Incorrect because a green zone reading indicates controlled asthma, and no immediate action is required.
C. "I will slowly exhale through the mouthpiece over a 10-second interval.": Incorrect because the exhalation should be rapid and forceful to measure peak flow effectively.
D. "I will record the highest reading of the three attempts." Recording the highest reading ensures accurate monitoring of airway status and helps the child track their progress over time.
Correct Answer is D
Explanation
A. Cover the equipment used in the infant's care prior to the parents' first visit: While this might reduce visual distress, it does not directly support the grieving process or involve the parents in meaningful interactions.
B. Reduce the parents' distress by limiting the duration of their visit: Limiting visit time may increase distress by reducing opportunities for the parents to process emotions.
C. Avoid leaving the parents alone with the infant during their visit: Parents may value privacy to express their feelings and bond with the infant without outside observation.
D. Involve the parents in the infant's caregiving activities during their visit. Involving parents in caregiving helps them feel connected to their child and provides meaningful time to bond, which supports healthy grieving.
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